Abnorm psych lec pwrpt. ch11


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Abnorm psych lec pwrpt. ch11

  1. 1. Sexual Disorders and Gender Identity Disorder Chapter 11
  2. 2. Sexual Disorders and Gender Identity Disorder <ul><li>Sexual behavior is a major focus of both our private thoughts and public discussions </li></ul><ul><li>Experts recognize two general categories of sexual disorders: </li></ul><ul><ul><li>Sexual dysfunctions – problems with sexual responses </li></ul></ul><ul><ul><li>Paraphilias – repeated and intense sexual urges and fantasies in response to socially inappropriate objects or situations </li></ul></ul>
  3. 3. Sexual Disorders and Gender Identity Disorder <ul><li>DSM-IV-TR also includes a diagnosis of gender identity disorder, a sex-related pattern in which people feel that they have been assigned to the wrong sex </li></ul><ul><li>Relatively little is known about racial and other cultural differences in sexuality </li></ul><ul><ul><li>Sex therapists and sex researchers have only recently begun to attend systematically to the importance of culture and race </li></ul></ul>
  4. 4. Sexual Dysfunctions <ul><li>Sexual dysfunctions are disorders in which people cannot respond normally in key areas of sexual functioning </li></ul><ul><ul><li>As many as 31% of men and 43% of women in the U.S. suffer from such a dysfunction during their lives </li></ul></ul><ul><li>Sexual dysfunctions are typically very distressing, and often lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems </li></ul><ul><ul><li>Often these dysfunctions are interrelated; many patients with one dysfunction experience another as well </li></ul></ul>
  5. 5. Sexual Dysfunctions <ul><li>The human sexual response can be described as a cycle with four phases: </li></ul><ul><ul><li>Desire </li></ul></ul><ul><ul><li>Excitement </li></ul></ul><ul><ul><li>Orgasm </li></ul></ul><ul><ul><li>Resolution </li></ul></ul><ul><li>Sexual dysfunctions affect one or more of the first three phases </li></ul>
  7. 8. Sexual Dysfunctions <ul><li>Some people struggle with sexual dysfunction their whole lives </li></ul><ul><ul><li>For others, normal sexual functioning preceded the disorder </li></ul></ul><ul><li>In some cases the dysfunction is present during all sexual situations </li></ul><ul><ul><li>In others it is tied to particular situations </li></ul></ul>
  8. 9. Disorders of Desire <ul><li>Desire phase of the sexual response cycle </li></ul><ul><ul><li>Consists of an urge to have sex, sexual fantasies, and sexual attraction to others </li></ul></ul><ul><li>Two dysfunctions affect this phase: </li></ul><ul><ul><li>Hypoactive sexual desire disorder </li></ul></ul><ul><ul><li>Sexual aversion disorder </li></ul></ul>
  9. 10. Disorders of Desire <ul><li>Hypoactive sexual desire disorder </li></ul><ul><ul><li>Characterized by a lack of interest in sex and little sexual activity </li></ul></ul><ul><ul><ul><li>Physical responses may be normal </li></ul></ul></ul><ul><ul><li>Prevalent in about 16% of men and 33% of women </li></ul></ul><ul><ul><li>DSM-IV-TR refers to “deficient” sexual interest/activity but provides no definition of “deficient” </li></ul></ul><ul><ul><ul><li>In reality, this criterion is difficult to define </li></ul></ul></ul>
  10. 11. Disorders of Desire <ul><li>Sexual aversion disorder </li></ul><ul><ul><li>Find sex distinctly unpleasant or repulsive </li></ul></ul><ul><ul><ul><li>Sexual advances may sicken, disgust, or frighten </li></ul></ul></ul><ul><ul><li>This disorder seems to be rare in men and more common in women </li></ul></ul>
  11. 12. Disorders of Desire <ul><li>A person’s sex drive is determined by a combination of biological, psychological, and sociocultural factors, and any of these may reduce sexual desire </li></ul><ul><li>Most cases of low sexual desire or sexual aversion are caused primarily by sociocultural and psychological factors, but biological conditions can also lower sex drive significantly </li></ul>
  12. 13. Disorders of Desire <ul><li>Biological causes </li></ul><ul><ul><li>A number of hormones interact to produce sexual desire and behavior </li></ul></ul><ul><ul><ul><li>Abnormalities in their activity can lower sex drive </li></ul></ul></ul><ul><ul><ul><li>These hormones include prolactin, testosterone, and estrogen for both men and women </li></ul></ul></ul><ul><ul><li>Sex drive can also be lowered by long-term physical illness, some medications (including birth control pills), some psychotropic drugs, and a number of illegal drugs </li></ul></ul>
  13. 14. Disorders of Desire <ul><li>Psychological causes </li></ul><ul><ul><li>A general increase in anxiety, depression, or anger may reduce sexual desire in both women and men </li></ul></ul><ul><ul><li>Fears, attitudes, and memories may contribute to sexual dysfunction </li></ul></ul><ul><ul><li>Certain psychological disorders may lead to sexual desire disorders, including depression and obsessive-compulsive disorder, </li></ul></ul>
  14. 15. Disorders of Desire <ul><li>Sociocultural causes </li></ul><ul><ul><li>Attitudes, fears, and psychological disorders that contribute to sexual desire disorders occur within a social context </li></ul></ul><ul><ul><ul><li>Many sufferers of desire disorders are feeling situational pressures </li></ul></ul></ul><ul><ul><ul><ul><li>Examples: divorce, death, job stress, infertility, and/or relationship difficulties </li></ul></ul></ul></ul><ul><ul><ul><li>Cultural standards can impact the development of these disorders </li></ul></ul></ul><ul><ul><ul><li>The trauma of sexual molestation or assault is also likely to produce sexual dysfunction </li></ul></ul></ul>
  15. 16. Disorders of Excitement <ul><li>Excitement phase of the sexual response cycle </li></ul><ul><ul><li>Marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing </li></ul></ul><ul><ul><ul><li>In men: erection of the penis </li></ul></ul></ul><ul><ul><ul><li>In women: swelling of the clitoris and labia and vaginal lubrication </li></ul></ul></ul><ul><li>Two dysfunctions affect this phase: </li></ul><ul><ul><li>Female sexual arousal disorder (formerly “frigidity”) </li></ul></ul><ul><ul><li>Male erectile disorder (formerly “impotence”) </li></ul></ul>
  16. 17. Disorders of Excitement <ul><li>Female sexual arousal disorder </li></ul><ul><ul><li>Characterized by repeated inability to maintain proper lubrication or genital swelling during sexual activity </li></ul></ul><ul><ul><ul><li>Many with this disorder also have desire or orgasmic disorders </li></ul></ul></ul><ul><ul><li>It is estimated that more than 10% of women experience this disorder </li></ul></ul><ul><ul><li>Because this disorder is so often tied to an orgasmic disorder, researchers usually study the two together; causes of the two disorders will be examined together </li></ul></ul>
  17. 18. Disorders of Excitement <ul><li>Male erectile disorder (ED) </li></ul><ul><ul><li>Characterized by repeated inability to attain or maintain an adequate erection during sexual activity </li></ul></ul><ul><ul><li>An estimated 10% of men experience this disorder </li></ul></ul><ul><ul><li>According to surveys, half of all adult men have erectile difficulty during intercourse at least some of the time </li></ul></ul>
  18. 19. Disorders of Excitement <ul><li>Most cases of erectile disorder result from an interaction of biological, psychological, and sociocultural processes </li></ul>
  19. 20. Disorders of Excitement <ul><li>Biological causes </li></ul><ul><ul><li>The same hormonal imbalances that can cause hypoactive sexual desire can also produce ED </li></ul></ul><ul><ul><li>Most commonly, vascular problems are involved </li></ul></ul><ul><ul><ul><li>ED can also be caused by damage to the nervous system from various diseases, disorders, or injuries </li></ul></ul></ul><ul><ul><li>The use of certain medications and substances may interfere with erections </li></ul></ul>
  20. 21. Disorders of Excitement <ul><li>Biological causes </li></ul><ul><ul><li>Medical procedures have been developed for diagnosing biological causes of ED </li></ul></ul><ul><ul><ul><li>One strategy involves measuring nocturnal penile tumescence (NPT) </li></ul></ul></ul><ul><ul><ul><ul><li>Men typically have erections during REM sleep; abnormal or absent nighttime erections usually indicate a physical basis for erectile failure </li></ul></ul></ul></ul>
  21. 22. Disorders of Excitement <ul><li>Psychological causes </li></ul><ul><ul><li>Any of the psychological causes of hypoactive sexual desire can also interfere with arousal and lead to erectile dysfunction </li></ul></ul><ul><ul><ul><li>For example, as many as 90% of men with severe depression experience some degree of ED </li></ul></ul></ul><ul><ul><li>One well-supported cognitive explanation for ED emphasizes performance anxiety and the spectator role </li></ul></ul><ul><ul><ul><li>Once a man begins to have erectile difficulties, he becomes fearful and worried during sexual encounters; instead of being a participant, he becomes a spectator and judge </li></ul></ul></ul><ul><ul><ul><ul><li>This can create a vicious cycle of sexual dysfunction where the original cause of the erectile failure becomes less important than the fear of failure </li></ul></ul></ul></ul>
  22. 23. Disorders of Excitement <ul><li>Sociocultural causes </li></ul><ul><ul><li>Each of the sociocultural factors tied to hypoactive sexual desire has also been linked to ED </li></ul></ul><ul><ul><ul><li>Job and marital distress are particularly relevant </li></ul></ul></ul>
  23. 24. Disorders of Orgasm <ul><li>Orgasm phase of the sexual response cycle </li></ul><ul><ul><li>Sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract rhythmically </li></ul></ul><ul><ul><ul><li>For men: semen is ejaculated </li></ul></ul></ul><ul><ul><ul><li>For women: the outer third of the vaginal walls contract </li></ul></ul></ul><ul><li>There are three disorders of this phase: </li></ul><ul><ul><li>Rapid, or Premature, ejaculation </li></ul></ul><ul><ul><li>Male orgasmic disorder </li></ul></ul><ul><ul><li>Female orgasmic disorder </li></ul></ul>
  24. 25. Disorders of Orgasm <ul><li>Rapid, or Premature, ejaculation </li></ul><ul><ul><li>Characterized by persistent reaching of orgasm and ejaculation with little sexual stimulation </li></ul></ul><ul><ul><ul><li>About 30% of men experience rapid ejaculation at some time </li></ul></ul></ul><ul><ul><li>Psychological, particularly behavioral, explanations of this disorder have received more research support than other explanations </li></ul></ul><ul><ul><ul><li>The dysfunction seems to be common in young, sexually inexperienced men </li></ul></ul></ul><ul><ul><ul><li>It may also be related to anxiety, hurried masturbation experiences, or poor recognition of arousal </li></ul></ul></ul>
  25. 26. Disorders of Orgasm <ul><li>Rapid, or Premature, ejaculation </li></ul><ul><ul><li>There is a growing belief among many clinical theorists that biological factors may also play a key role in many cases of this disorder </li></ul></ul><ul><ul><ul><li>One theory states that some men are born with a genetic predisposition </li></ul></ul></ul><ul><ul><ul><li>A second theory argues that the brains of men with rapid ejaculation contain certain serotonin receptors that are overactive and others that are underactive </li></ul></ul></ul><ul><ul><ul><li>A third explanation holds that men with this dysfunction experience greater sensitivity or nerve conduction in the area of their penis </li></ul></ul></ul>
  26. 27. Disorders of Orgasm <ul><li>Male orgasmic disorder </li></ul><ul><ul><li>Characterized by a repeated inability to reach orgasm or by a very delayed orgasm after normal sexual excitement </li></ul></ul><ul><ul><ul><li>Occurs in 8% of the male population </li></ul></ul></ul><ul><ul><li>Biological causes include low testosterone, neurological disease, and head or spinal cord injury </li></ul></ul><ul><ul><ul><li>Medications, including certain antidepressants (especially SSRIs) and drugs that slow down the central nervous system (CNS), can also affect ejaculation </li></ul></ul></ul>
  27. 28. Disorders of Orgasm <ul><li>Male orgasmic disorder </li></ul><ul><ul><li>A leading psychological cause appears to be performance anxiety and the spectator role, the cognitive-behavioral factors involved in ED </li></ul></ul><ul><ul><li>Another psychological cause may be past masturbation habits </li></ul></ul><ul><ul><li>Finally, the disorder may develops out of hypoactive sexual desire </li></ul></ul>
  28. 29. Disorders of Orgasm <ul><li>Female orgasmic disorder </li></ul><ul><ul><li>Characterized by persistent delay in or absence of orgasm following normal sexual excitement </li></ul></ul><ul><ul><ul><li>Almost 25% of women appear to have this problem </li></ul></ul></ul><ul><ul><ul><ul><li>10% or more have never reached orgasm </li></ul></ul></ul></ul><ul><ul><ul><ul><li>An additional 9% reach orgasm only rarely </li></ul></ul></ul></ul><ul><ul><ul><li>Women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly </li></ul></ul></ul><ul><ul><ul><li>Female orgasmic disorder is more common in single women than in married or cohabiting women </li></ul></ul></ul>
  29. 30. Disorders of Orgasm <ul><li>Female orgasmic disorder </li></ul><ul><ul><li>Most clinicians agree that orgasm during intercourse is not mandatory for normal sexual functioning </li></ul></ul><ul><ul><ul><li>Early psychoanalytic theory used to consider lack of orgasm during intercourse to be pathological </li></ul></ul></ul><ul><ul><li>Typically linked to female sexual arousal disorder </li></ul></ul><ul><ul><ul><li>The two disorders tend to be studied and treated together </li></ul></ul></ul><ul><ul><li>Once again, biological, psychological, and sociocultural factors may combine to produce these disorders </li></ul></ul>
  30. 31. Disorders of Orgasm <ul><li>Female orgasmic disorder </li></ul><ul><ul><li>Biological causes </li></ul></ul><ul><ul><ul><li>A variety of physiological conditions can affect a woman’s arousal and orgasm </li></ul></ul></ul><ul><ul><ul><ul><li>These conditions include diabetes and multiple sclerosis </li></ul></ul></ul></ul><ul><ul><ul><li>The same medications and illegal substances that affect erection in men can affect arousal and orgasm in women </li></ul></ul></ul><ul><ul><ul><li>Postmenopausal changes may also be responsible </li></ul></ul></ul>
  31. 32. Disorders of Orgasm <ul><li>Female orgasmic disorder </li></ul><ul><ul><li>Psychological causes </li></ul></ul><ul><ul><ul><li>The psychological causes of hypoactive sexual desire and sexual aversion, including depression, may also lead to female arousal and orgasmic disorders </li></ul></ul></ul><ul><ul><ul><li>Memories of childhood trauma and relationship distress may also be related </li></ul></ul></ul>
  32. 33. Disorders of Orgasm <ul><li>Female orgasmic disorder </li></ul><ul><ul><li>Sociocultural causes </li></ul></ul><ul><ul><ul><li>For years, the leading sociocultural theory of female sexual dysfunction was that it resulted from sexually restrictive cultural messages </li></ul></ul></ul><ul><ul><ul><li>This theory has been challenged because: </li></ul></ul></ul><ul><ul><ul><ul><li>Sexually restrictive histories are equally common in women with and without disorders </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cultural messages about female sexuality have been changing while the rate of female sexual dysfunction stays constant </li></ul></ul></ul></ul>
  33. 34. Disorders of Orgasm <ul><li>Female orgasmic disorder </li></ul><ul><ul><li>Sociocultural causes </li></ul></ul><ul><ul><ul><li>Researchers suggest that unusually stressful events or relationships may produce the fears, memories, and attitudes that characterize these dysfunctions </li></ul></ul></ul><ul><ul><ul><li>Research has also linked certain qualities in a woman’s intimate relationships (such as emotional intimacy) to orgasmic behavior </li></ul></ul></ul>
  34. 35. Disorders of Sexual Pain <ul><li>Two sexual dysfunctions do not fit neatly into a specific phase of the sexual response cycle </li></ul><ul><ul><li>These are the sexual pain disorders: </li></ul></ul><ul><ul><ul><li>Vaginismus </li></ul></ul></ul><ul><ul><ul><li>Dyspareunia </li></ul></ul></ul>
  35. 36. Disorders of Sexual Pain <ul><li>Vaginismus </li></ul><ul><ul><li>Characterized by involuntary contractions of the muscles of the outer third of the vagina </li></ul></ul><ul><ul><ul><li>Severe cases can prevent a woman from having intercourse </li></ul></ul></ul><ul><ul><ul><li>Perhaps 20% of women occasionally have pain during intercourse, but less than 1% of all women have vaginismus </li></ul></ul></ul>
  36. 37. Disorders of Sexual Pain <ul><li>Vaginismus </li></ul><ul><ul><li>Most clinicians agree with the cognitive-behavioral theory that vaginismus is a learned fear response </li></ul></ul><ul><ul><ul><li>A variety of factors can set the stage for this fear, including anxiety and ignorance about intercourse, trauma caused by an unskilled partner, and childhood sexual abuse </li></ul></ul></ul><ul><ul><li>Some women experience painful intercourse because of infection or disease </li></ul></ul><ul><ul><li>Most women with vaginismus also have other sexual disorders </li></ul></ul>
  37. 38. Disorders of Sexual Pain <ul><li>Dyspareunia </li></ul><ul><ul><li>Characterized by severe pain in the genitals during sexual activity </li></ul></ul><ul><ul><ul><li>As almost 14% of women and about 3% of men </li></ul></ul></ul><ul><ul><li>Dyspareunia in women usually has a physical cause, most commonly from injury sustained in childbirth </li></ul></ul><ul><ul><li>Although psychological factors or relationship problems may contribute to dyspareunia, psychosocial factors alone are rarely responsible </li></ul></ul>
  38. 39. Treatments for Sexual Dysfunctions <ul><li>The last 35 years have brought major changes in the treatment of sexual dysfunction </li></ul><ul><ul><li>Early 20th century: psychodynamic therapy </li></ul></ul><ul><ul><ul><li>Believed that sexual dysfunction was caused by a failure to negotiate the stages of psychosexual development </li></ul></ul></ul><ul><ul><ul><li>Therapy focused on gaining insight and making broad personality changes; was generally unhelpful </li></ul></ul></ul>
  39. 40. Treatments for Sexual Dysfunctions <ul><li>1950s and 1960s: behavioral therapy </li></ul><ul><ul><li>Behavioral therapists attempted to reduce fear by applying relaxation training and systematic desensitization </li></ul></ul><ul><ul><li>Had some success, but failed to work in cases where the key problems included misinformation, negative attitudes, and lack of effective sexual techniques </li></ul></ul>
  40. 41. Treatments for Sexual Dysfunctions <ul><li>1970: Human Sexual Inadequacy </li></ul><ul><ul><li>This book, written by William Masters and Virginia Johnson, revolutionized treatment of sexual dysfunctions </li></ul></ul><ul><ul><li>This original “sex therapy” program has evolved into a complex, multidimensional approach </li></ul></ul><ul><ul><ul><li>Includes techniques from cognitive, behavioral, couples, and family systems therapies, along with a number of sex-specific techniques </li></ul></ul></ul><ul><ul><ul><li>More recently, biological interventions have also been incorporated </li></ul></ul></ul>
  41. 42. What Are the General Features of Sex Therapy? <ul><li>Modern sex therapy is short-term and instructive </li></ul><ul><ul><li>Therapy typically lasts 15 to 20 sessions </li></ul></ul><ul><ul><li>It centers on specific sexual problems rather than on broad personality issues </li></ul></ul>
  42. 43. What Are the General Features of Sex Therapy? <ul><li>Modern sex therapy includes: </li></ul><ul><ul><li>Assessment and conceptualization of the problem </li></ul></ul><ul><ul><li>Assigning “mutual responsibility” for the problem </li></ul></ul><ul><ul><li>Education about sexuality </li></ul></ul><ul><ul><li>Attitude change </li></ul></ul><ul><ul><li>Elimination of performance anxiety and the spectator role </li></ul></ul><ul><ul><li>Increasing sexual and general communication skills </li></ul></ul><ul><ul><li>Changing destructive lifestyles and marital interactions </li></ul></ul><ul><ul><li>Addressing physical and medical factors </li></ul></ul>
  43. 44. What Techniques Are Applied to Particular Dysfunctions? <ul><li>In addition to the universal components of sex therapy, specific techniques can help in each of the sexual dysfunctions </li></ul>
  44. 45. What Techniques Are Applied to Particular Dysfunctions? <ul><li>Hypoactive sexual desire and sexual aversion </li></ul><ul><ul><li>These disorders are among the most difficult to treat because of the many issues that feed into them </li></ul></ul><ul><ul><li>Therapists typically apply a combination of techniques, which may include: </li></ul></ul><ul><ul><ul><li>Affectual awareness, self-instruction training, behavioral techniques, insight-oriented exercises, and biological interventions such as hormone treatments </li></ul></ul></ul>
  45. 46. What Techniques Are Applied to Particular Dysfunctions? <ul><li>Erectile disorder </li></ul><ul><ul><li>Treatments for ED focus on reducing a man’s performance anxiety and/or increasing his stimulation </li></ul></ul><ul><ul><ul><li>May include sensate-focus exercises such as the “tease technique” </li></ul></ul></ul>
  46. 47. What Techniques Are Applied to Particular Dysfunctions? <ul><li>Erectile disorder </li></ul><ul><ul><li>Biological approaches have gained great momentum with the development of sildenafil (Viagra) and other erectile dysfunction drugs </li></ul></ul><ul><ul><ul><li>Most other biological approaches have been around for decades and include gels, suppositories, penile injections, and a vacuum erection device (VED) </li></ul></ul></ul><ul><ul><ul><ul><li>These procedures are now viewed as “second-line” treatment </li></ul></ul></ul></ul>
  47. 48. What Techniques Are Applied to Particular Dysfunctions? <ul><li>Male orgasmic disorder </li></ul><ul><ul><li>Like treatment for ED, therapies for this disorder include techniques to reduce performance anxiety and increase stimulation </li></ul></ul><ul><ul><li>When the cause of the disorder is physical, treatment may include a drug to increase arousal of the sympathetic nervous system </li></ul></ul>
  48. 49. What Techniques Are Applied to Particular Dysfunctions? <ul><li>Rapid, or Premature, ejaculation </li></ul><ul><ul><li>Premature ejaculation has been successfully treated for years by behavioral procedures such as the “stop-start” or “pause” procedure </li></ul></ul><ul><ul><li>Some clinicians favor the use of SSRIs, serotonin-enhancing antidepressant drugs </li></ul></ul><ul><ul><ul><li>Because these drugs often reduce sexual arousal or orgasm, they may be helpful in delaying premature ejaculation </li></ul></ul></ul><ul><ul><ul><li>Many studies have reported positive results with this approach </li></ul></ul></ul>
  49. 50. What Techniques Are Applied to Particular Dysfunctions? <ul><li>Female arousal and orgasmic disorders </li></ul><ul><ul><li>Specific treatments for these disorders include cognitive-behavioral techniques, self-exploration, enhancement of body awareness, and directed masturbation training </li></ul></ul>
  50. 51. What Techniques Are Applied to Particular Dysfunctions? <ul><li>Female arousal and orgasmic disorders </li></ul><ul><ul><li>Again, a lack of orgasm during intercourse is not necessarily a sexual dysfunction, provided the woman enjoys intercourse and is orgasmic through other means </li></ul></ul><ul><ul><ul><li>For this reason, some therapists believe that the wisest course of action is simply to educate women whose only concern is lack of orgasm through intercourse </li></ul></ul></ul>
  51. 52. What Techniques Are Applied to Particular Dysfunctions? <ul><li>Vaginismus </li></ul><ul><ul><li>Specific treatment for vaginismus takes two approaches: </li></ul></ul><ul><ul><ul><li>Practice tightening and releasing the muscles of the vagina to gain more voluntary control </li></ul></ul></ul><ul><ul><ul><li>Overcome fear of intercourse through gradual behavioral exposure treatment </li></ul></ul></ul><ul><ul><li>Most women treated for vaginismus using these methods eventually report pain-free intercourse </li></ul></ul>
  52. 53. What Techniques Are Applied to Particular Dysfunctions? <ul><li>Dyspareunia </li></ul><ul><ul><li>Determining the specific cause of dyspareunia is the first stage of treatment </li></ul></ul><ul><ul><ul><li>Given that most cases are caused by physical problems, medical intervention may be necessary </li></ul></ul></ul>
  53. 54. What Are the Current Trends in Sex Therapy? <ul><li>Over the past 30 years, sex therapists have moved beyond the approach first developed by Masters and Johnson </li></ul><ul><ul><li>Therapists now treat unmarried couples, those with other psychological disorders, couples with severe marital discord, the elderly, the medically ill, the physically handicapped, gay clients, and clients with no long-term sex partner </li></ul></ul>
  54. 55. What Are the Current Trends in Sex Therapy? <ul><li>Therapists are paying more attention to excessive sexuality, which is sometimes called hypersexuality or sexual addiction </li></ul><ul><li>The use of medications to treat sexual dysfunction is troubling to many therapists </li></ul><ul><ul><li>They are concerned that therapists will choose biological interventions rather than a more integrated approach </li></ul></ul>
  55. 56. Paraphilias <ul><li>These disorders are characterized by unusual fantasies and sexual urges or behaviors that are recurrent and sexually arousing </li></ul><ul><ul><li>Often involve: </li></ul></ul><ul><ul><ul><li>Nonhuman objects </li></ul></ul></ul><ul><ul><ul><li>Children </li></ul></ul></ul><ul><ul><ul><li>Non-consenting adults </li></ul></ul></ul><ul><ul><ul><li>Humiliation of self or partner </li></ul></ul></ul>
  56. 57. Paraphilias <ul><li>According to the DSM-IV-TR, paraphilias should be diagnosed only when the urges, fantasies, or behaviors last at least 6 months </li></ul><ul><ul><li>For most paraphilias, the urges, fantasies, or behaviors must also cause great distress or impairment </li></ul></ul><ul><ul><ul><li>For certain paraphilias, however, performance of the behavior itself is indicative of a disorder, even if the individual experiences no distress or impairment </li></ul></ul></ul><ul><ul><ul><ul><li>Example: sexual contact with children </li></ul></ul></ul></ul>
  57. 58. Paraphilias <ul><li>Some people with one kind of paraphilia display others as well </li></ul><ul><ul><li>Relatively few people receive a formal diagnosis, but clinicians believe that the patterns may be quite common </li></ul></ul>
  58. 59. Paraphilias <ul><li>Although theorists have proposed various explanations for paraphilias, there is little formal evidence to support them </li></ul><ul><ul><li>None of the treatments applied to paraphilias have received much research or been proved clearly effective </li></ul></ul><ul><ul><li>Psychological and sociocultural treatments have been available the longest, but today’s professionals are also using biological interventions </li></ul></ul>
  59. 60. Fetishism <ul><li>The key features of fetishism are recurrent intense sexual urges, sexually arousing fantasies, or behaviors that involve the use of a nonliving object, often to the exclusion of all other stimuli </li></ul><ul><ul><li>The disorder is far more common in men than women and usually begins in adolescence </li></ul></ul><ul><ul><li>Almost anything can be a fetish </li></ul></ul><ul><ul><ul><li>Women’s underwear, shoes, and boots are especially common </li></ul></ul></ul>
  60. 61. Fetishism <ul><li>Researchers have been unable to pinpoint the causes of fetishism </li></ul>
  61. 62. Fetishism <ul><li>Behaviorists propose that fetishes are acquired through classical conditioning </li></ul><ul><ul><li>Fetishes are sometimes treated with aversion therapy or imaginal exposure </li></ul></ul><ul><ul><li>Another behavioral treatment is masturbatory satiation, in which clients masturbate to boredom while imagining the fetish object </li></ul></ul><ul><ul><li>An additional behavioral treatment is orgasmic reorientation, a process which teaches individuals to respond to more appropriate sources of sexual stimulation </li></ul></ul>
  62. 63. Transvestic Fetishism <ul><li>Also known as transvestism or cross-dressing </li></ul><ul><li>Characterized by fantasies, urges, or behaviors involving dressing in the clothes of the opposite sex in order to achieve sexual arousal </li></ul>
  63. 64. Transvestic Fetishism <ul><li>The typical person with transvestism is a heterosexual male who began cross-dressing in childhood or adolescence </li></ul><ul><li>Transvestism is often confused with gender identity disorder (transsexualism), but the two are separate patterns </li></ul><ul><li>The development of the disorder seems to follow the behavioral principles of operant conditioning </li></ul>
  64. 65. Exhibitionism <ul><li>Characterized by arousal from the exposure of genitals in a public setting </li></ul><ul><ul><li>Sexual contact is neither initiated nor desired </li></ul></ul><ul><li>Usually begins before age 18 and is most common in males </li></ul><ul><li>Treatment generally includes aversion therapy and masturbatory satiation </li></ul><ul><ul><li>May be combined with orgasmic reorientation, social skills training, or cognitive-behavioral therapy </li></ul></ul>
  65. 66. Voyeurism <ul><li>Characterized by repeated and intense sexual desires to observe people as they undress or to spy on couples having intercourse </li></ul><ul><ul><li>The person may masturbate during the act of observing or while remembering it later </li></ul></ul><ul><ul><li>The risk of discovery often adds to the excitement </li></ul></ul>
  66. 67. Voyeurism <ul><li>Many psychodynamic theorists propose that voyeurs are seeking power </li></ul><ul><li>Behaviorists explain voyeurism as a learned behavior that can be traced to a chance and secret observation of a sexually arousing scene </li></ul>
  67. 68. Frotteurism <ul><li>A person who develops frotteurism has recurrent and intense fantasies, urges, or behaviors involving touching and rubbing against a nonconsenting person </li></ul><ul><ul><li>Almost always male, the person fantasizes during the act that he is having a caring relationship with the victim </li></ul></ul><ul><li>Usually begins in the teen years or earlier </li></ul><ul><ul><li>Acts generally decrease and disappear after age 25 </li></ul></ul>
  68. 69. Pedophilia <ul><li>Characterized by fantasies, urges, or behaviors involving sexual activity with a prepubescent child, usually 13 years of age or younger </li></ul><ul><ul><li>Some people are satisfied with child pornography </li></ul></ul><ul><ul><li>Others are driven to watching, fondling, or engaging in sexual intercourse with children </li></ul></ul><ul><ul><li>Victims may be male, but evidence suggests that two-thirds of victims are female </li></ul></ul>
  69. 70. Pedophilia <ul><li>People with pedophilia develop the disorder in adolescence </li></ul><ul><ul><li>Some were sexually abused as children </li></ul></ul><ul><ul><ul><li>Many were neglected, excessively punished, or deprived of close relationships in childhood </li></ul></ul></ul><ul><ul><li>Most are immature, display distorted thinking, and have an additional psychological disorder </li></ul></ul><ul><ul><ul><li>Some theorists have proposed a related biochemical or brain structure abnormality but clear biological factors have yet to emerge in research </li></ul></ul></ul>
  70. 71. Pedophilia <ul><li>Most people with pedophilia are imprisoned or forced into treatment </li></ul><ul><ul><li>Treatments include aversion therapy, masturbatory satiation, orgasmic reorientation, and treatment with antiandrogen drugs </li></ul></ul><ul><ul><li>Cognitive-behavioral treatment involves relapse-prevention training, modeled after programs used for substance dependence </li></ul></ul>
  71. 72. Sexual Masochism <ul><li>Characterized by fantasies, urges, or behaviors involving the act or the thought of being humiliated, beaten, bound, or otherwise made to suffer </li></ul><ul><li>Most masochistic fantasies begin in childhood and seem to develop through the behavioral process of classical conditioning </li></ul>
  72. 73. Sexual Sadism <ul><li>A person with sexual sadism finds fantasies, urges, or behaviors involving the thought or act of psychological or physical suffering of a victim sexually exciting </li></ul><ul><ul><li>Named for the infamous Marquis de Sade </li></ul></ul><ul><ul><li>People with sexual sadism imagine that they have total control over a sexual victim </li></ul></ul>
  73. 74. Sexual Sadism <ul><li>Sadistic fantasies may first appear in childhood </li></ul><ul><ul><li>Pattern is long-term </li></ul></ul><ul><ul><li>Appears to be related to classical conditioning </li></ul></ul><ul><li>Psychodynamic and cognitive theorists view people with sexual sadism as having underlying feelings of sexual inadequacy </li></ul>
  74. 75. Sexual Sadism <ul><li>Biological studies have found possible abnormalities in the endocrine system </li></ul><ul><li>The primary treatment for this disorder is aversion therapy </li></ul>
  75. 76. A Word of Caution <ul><li>The definitions of paraphilias, like those of sexual dysfunctions, are strongly influenced by the norms of the particular society in which they occur </li></ul><ul><li>Some clinicians argue that, except when people are hurt by them, paraphilic behaviors should not be considered disorders at all </li></ul>
  76. 77. Gender Identity Disorder <ul><li>According to current DSM-IV-TR criteria, people with this disorder persistently feel that they have been assigned to the wrong biological sex </li></ul><ul><ul><li>They would like to remove their primary and secondary sex characteristics and acquire the characteristics of the opposite sex </li></ul></ul>
  77. 78. Gender Identity Disorder <ul><li>The DSM-IV-TR categorization of this disorder has become controversial in recent years </li></ul><ul><ul><li>Many people believe that transgender experiences reflect alternative – not pathological – ways of experiencing one’s gender identity </li></ul></ul><ul><ul><li>Others argue that gender identity disorder is, in fact, a medical problem that may produce personal unhappiness </li></ul></ul>
  78. 79. Gender Identity Disorder <ul><li>Men with gender identity disorder outnumber women 2 to 1 </li></ul><ul><li>People with gender identity disorder often experience anxiety or depression and may have thoughts of suicide </li></ul>
  79. 80. Gender Identity Disorder <ul><li>The disorder sometimes emerges in childhood and disappears with adolescence </li></ul><ul><ul><li>In some cases it develops into adult gender identity disorder </li></ul></ul>
  80. 81. Gender Identity Disorder <ul><li>Various theories have been proposed to explain this disorder, but research is limited and generally weak </li></ul><ul><ul><li>Many clinicians suspect biological – perhaps genetic or prenatal – factors </li></ul></ul><ul><ul><ul><li>Abnormalities in the hypothalamus (particularly the bed nucleus of stria terminalis) are a potential link </li></ul></ul></ul>
  81. 82. Gender Identity Disorder <ul><li>To more effectively assess and treat those with the disorder, clinical theorists have tried to distinguish the most common patterns of gender dysphoria: </li></ul><ul><ul><li>Female-to-male </li></ul></ul><ul><ul><li>Male-to-female: Androphilic Type </li></ul></ul><ul><ul><li>Male-to-female: Autogyneophilic Type </li></ul></ul>
  82. 83. Gender Identity Disorder <ul><li>Many people with GID receive psychotherapy, but a large number of them further seek biological interventions </li></ul><ul><ul><li>Some adults with this disorder change their sexual characteristics by way of hormones; others opt for sexual reassignment (sex change) surgery </li></ul></ul>
  83. 84. Gender Identity Disorder <ul><li>Clinicians have debated heatedly whether sexual reassignment is an appropriate treatment </li></ul><ul><ul><li>Research into the outcomes of gender reassignment surgery points in favorable directions, although most studies have key methodological flaws </li></ul></ul>